Analysis Operating Practices Company operating practices were such that various drivers were assigned to a vehicle, and the daily preparation and in-service handover procedures were not formally monitored or recorded. The vehicle service personnel would verbally accept completion of these routine safety-related functions and did not have a documented checklist. Training and instruction in vehicle in-service operation was hands-on and verbal. Standard operating instructions or emergency procedures were neither documented and maintained ashore, nor provided on the vehicles to guide the drivers. The vehicle's design necessitated closure of the seacocks for safe waterborne passenger service. However, their routine operation and closure solely depended on the drivers' diligence and was not formally monitored or recorded at the start of daily operation or while the vehicle was parked between tours. Had a documented in-service checking system been in place, the main safety defence against accidental or inadvertent ingress of water would not have been lost. Relying solely on the verbal sharing of essential safety-related operating information among the Hull garage, the driver, and the company kiosk in Ottawa contributed to the vehicle beginning passenger-carrying service with all seacocks open. Emergency Response Because there was no formal emergency preparedness or response plan, the driver was unsure of the company department that should be informed first of the emergency situation. Company operational personnel in the Hull garage were contacted only after the initial cell phone call to the ticket kiosk in Ottawa. They subsequently arrived on scene after the safe evacuation of the passengers and in time to conduct the attempted recovery of the partially flooded vehicle. The fire departments of Ottawa, Hull, and Gatineau are equipped for marine emergency response duties when alerted via a 911 telephone call; however, the tour company and the driver were unaware of this marine-related service. The CCG is responsible for providing marine search-and-rescue (SAR) services, as shown in a diagram in the National SAR Manual. In considering the need for SAR resources in the Ottawa River, CCG assessed in its SAR planning exercise that there was no demonstrable evidence that dedicated government SAR resources should be established in the area. However, the CCG has historically provided SAR services up to the Portage Bridge (at Ottawa/Hull) by coordinating the provision of CCG auxiliary resources. These auxiliary craft only monitor emergency VHF channel16 intermittently. In accordance with the SAR plan, directional VHF antenna coverage of MCTS in Prescott, Ontario, and in Montral does not extend to the NCR. Hence, a vessel issuing a distress Mayday on channel16 must rely on local private, commercial, or auxiliary vessels that may or may not be monitoring the frequency, rather than having the call monitored directly by the MCTS, which has a direct line to the Rescue Coordination Centre, which can quickly dispatch necessary resources. In this occurrence, the emergency response from a private vessel and an RCMP craft was prompt, as was the assistance and the subsequent reporting of the sinking by GCU-480. However, of the numerous private and commercial craft in the area, only one responded to the emergency. Furthermore, the presence of the RCMP boat and GCU-480 was fortuitous: they were on temporary assignment to the NCR, monitoring a marine racing event scheduled that day. Vehicle Inspection The owner/builder has previously constructed and now operates two other amphibious passenger vehicles that, because of their larger size and greater passenger-carrying capacity, were inspected and accepted by TCMS. During the building and inspection of these vehicles, the owner gained some limited knowledge and experience of marine regulatory requirements and procedures. The owner/builder did not notify TCMS of the start of construction of the LadyDuck. Throughout the construction period and until after the vehicle sank, the owner was unaware that TCMS published SSBs addressing standards, safety requirements, and inspection and compliance programs applicable to small passenger vessels. Consequently, the owner/builder did not request copies of the applicable SSBs or seek inclusion in the TCMS mailing list for the routine distribution of such publications. Because TCMS was not notified of the start of construction, and no requests were received for SSBs or inclusion in the SSB distribution list, copies of these documents were not forwarded to the owner/builder. Consequently, a First Inspection was not carried out before the amphibious vehicle entered passenger-carrying service. Safe operation, seaworthiness, and compliance with applicable regulatory requirements and appropriate standards are the responsibility of every vessel owner/operator. Consequently, while the LadyDuck may not be described as a vessel, it is a commercially operated passenger-carrying waterborne craft and, as such, passenger safety requirements of vessel-related regulations and programs are appropriate. Had a First Inspection been carried out by TCMS before the LadyDuck entered service, shortcomings in the outfit of safety equipment, pumping, and firefighting arrangements found after the sinking and noted in the Detention Order would have been identified. In particular, routine hose pressure head tests of the bilge drainage valve system would have shown how ineffective the swing-check valves were in preventing the entry of water in the event of nonclosure or failure of the seacocks. The tests would have dispelled any reliance on this system as a secondary precautionary measure to ensure the watertight integrity of the vehicle. They would also have highlighted the necessity for increased emphasis on the monitoring of seacock operating procedures. The initial ingress of water was due to the open bilge drainage seacocks and the failure of the swing-check nonreturn valves to function as a back-up. The bilge pumps' location near the midlength of the vehicle precluded the discharge of floodwater that accumulated at the forward end of the trimmed vehicle. When the vehicle proceeded at slower speeds or was stopped, the rate of flooding increased due to the reduction or loss of venturi suction effect at the ends of the open seacocks. As the vehicle was being driven ashore, grounding effects raised the right side of the partially flooded hull and caused floodwater to gravitate to the left and increase the angle of heel. More water was shipped over the left side, downflooded into the hull, and caused the vehicle to suddenly capsize and sink. There was no formal system to monitor and record the closure of seacocks before the vehicle began its first scheduled tour of the day.Findings as to Causes and Contributing Factors The initial ingress of water was due to the open bilge drainage seacocks and the failure of the swing-check nonreturn valves to function as a back-up. The bilge pumps' location near the midlength of the vehicle precluded the discharge of floodwater that accumulated at the forward end of the trimmed vehicle. When the vehicle proceeded at slower speeds or was stopped, the rate of flooding increased due to the reduction or loss of venturi suction effect at the ends of the open seacocks. As the vehicle was being driven ashore, grounding effects raised the right side of the partially flooded hull and caused floodwater to gravitate to the left and increase the angle of heel. More water was shipped over the left side, downflooded into the hull, and caused the vehicle to suddenly capsize and sink. There was no formal system to monitor and record the closure of seacocks before the vehicle began its first scheduled tour of the day. The builder did not forward notice of the start or completion of the vehicle's construction to Transport Canada Marine Safety (TCMS) to seek a First Inspection in accordance with Ship Safety Bulletin 04/2001. The vehicle was not inspected by TCMS before it entered passenger-carrying operation. The builder did not request copies of ship safety bulletins addressing regulatory and safety requirements, standards, and inspection programs for small passenger vessels. Neither did he seek inclusion on the list maintained by TCMS for the routine distribution of such publications. There was no formal system to check and record the completion of routine vehicle preparation procedures before starting or during daily operation. Consistent with the Canadian Coast Guard's (CCG) Search and Rescue (SAR) plan, directional VHF antenna coverage of Marine Communications and Traffic Services in Prescott and in Montral does not extend to the National Capital Region. SAR response is limited to two CCG auxiliary craft-- and any other private or commercial craft in the area--that only monitor emergency channel16 intermittently.Findings as to Risk The builder did not forward notice of the start or completion of the vehicle's construction to Transport Canada Marine Safety (TCMS) to seek a First Inspection in accordance with Ship Safety Bulletin 04/2001. The vehicle was not inspected by TCMS before it entered passenger-carrying operation. The builder did not request copies of ship safety bulletins addressing regulatory and safety requirements, standards, and inspection programs for small passenger vessels. Neither did he seek inclusion on the list maintained by TCMS for the routine distribution of such publications. There was no formal system to check and record the completion of routine vehicle preparation procedures before starting or during daily operation. Consistent with the Canadian Coast Guard's (CCG) Search and Rescue (SAR) plan, directional VHF antenna coverage of Marine Communications and Traffic Services in Prescott and in Montral does not extend to the National Capital Region. SAR response is limited to two CCG auxiliary craft-- and any other private or commercial craft in the area--that only monitor emergency channel16 intermittently. The owner did not report the occurrence to any regulatory, licensing, or emergency response authority. The incorporation of externally mounted, hand-operated seacocks in lieu of conventional screwed drainage plugs was for operational convenience. Because the vehicle is less than 5 in gross tonnage and carries not more than 12passengers, it was not subject to the requirements of the Hull Construction Regulations and the Hull Inspection Regulations. The vehicle was required to comply with the applicable sections of the Small Vessel Regulations and the Interim Small Passenger Vessel Compliance Program. The presence of the Royal Canadian Mounted Police boat and GCU-480 at the time of the occurrence was fortuitous. The company had no formal emergency contingency plan, nor was the vehicle driver aware of the marine emergency response available by contacting local fire departments through 911.Other Findings The owner did not report the occurrence to any regulatory, licensing, or emergency response authority. The incorporation of externally mounted, hand-operated seacocks in lieu of conventional screwed drainage plugs was for operational convenience. Because the vehicle is less than 5 in gross tonnage and carries not more than 12passengers, it was not subject to the requirements of the Hull Construction Regulations and the Hull Inspection Regulations. The vehicle was required to comply with the applicable sections of the Small Vessel Regulations and the Interim Small Passenger Vessel Compliance Program. The presence of the Royal Canadian Mounted Police boat and GCU-480 at the time of the occurrence was fortuitous. The company had no formal emergency contingency plan, nor was the vehicle driver aware of the marine emergency response available by contacting local fire departments through 911. Safety Action Action Taken Transport Canada Transport Canada Marine Safety (TCMS) began a First Inspection in accordance with the Small Vessel Monitoring and Inspection Program on 03 July 2001. After the safety equipment deficiencies were satisfactorily addressed, TCMS rescinded the previously issued detention order on 20 July 2001. A copy of Ship Safety Bulletin 04/2001 was given to the owner of the LadyDuck. This bulletin included details of applicable standards, safety requirements, and inspection compliance requirements. The installation of screwed plugs in the outboard ends of all seacocks, fitted during the TCMS assessment of the vehicle's trim and intact transverse stability characteristics, was adopted by the owner as a future operating practice. Electrically driven pumps were installed in engine compartments at either end of the vehicle. The Ship Station (Radio) Regulations, 1999, is in the amendment process. These regulations prescribe the radio equipment to be carried by commercial vessels for distress, urgent, safety, and general communications. Passenger ships engaged on a voyage, any part of which is outside a VHF coverage area, will be required to be equipped with radio equipment capable of establishing continuous two-way communications with a Marine Communications and Traffic Services (MCTS) centre or a person ashore. The targeted date for pre-publishing in Canada Gazette, Part I, is autumn2002. Vehicle Owner The owner of the LadyDuck has amended company operating practices by mandating the completion of a safety checklist before each departure of the vehicle. Accordingly, the driver must verify the status of the seacocks, sign the safety checklist, and have it countersigned by the guide or the kiosk attendant for retention ashore. The list also includes the number of passengers on board. To prevent water from entering the front of the hull through inadvertent operation or malfunction of the vertical sliding visor, the visor is now bolted in the raised position when the vehicle is engaged in routine tourist operation. Safety Concerns SAR/MCTS Coverage The CCG's Search and Rescue (SAR) organization has overall responsibility for administering the national marine SAR program, including the provision of marine emergency channel 16 VHF radio coverage. According to a diagram in the National SAR Manual, the National Capital Region (NCR) stretch of the Ottawa River is within the SAR organization's area of responsibility, yet no government SAR resources are located in the NCR or the adjacent area. Vessels in this area rely on two auxiliary units and on local fire and police services. The NCR is outside the VHF monitoring range of MCTS Prescott and MCTS Montral. Thus, the local VHF radio monitoring and response services are only provided intermittently by CCG auxiliary craft and by private and other commercial craft in the area. Other services--such as 911 in Ottawa and Hull, cell phones, and other radio frequencies, ex. CBs--are used to report distress. Therefore, there is no official coordination of distress communications. Tourism is a growing industry in the NCR. In addition to numerous pleasure craft, some 19tourist vessels, including 4 amphibious vehicles, are currently in operation, representing a significant number of waterborne passengers. With such a number of private vessels, commercial passenger vessels, and amphibious vehicles in the Ottawa/Hull area, it is essential that effective marine SAR monitoring and response resources be available in the event of a marine emergency. In this occurrence, the presence of the Royal Canadian Mounted Police boat and GCU-480 was fortuitous. While the response of the private vessel was prompt, it was the only one of the numerous private vessels in the area to respond. The TSB report (M00L0043) of an occurrence in May 2000 involving the loss overboard of a passenger from the MissGatineaunoted that, while local marine rescue services responded quickly, subsequent SAR activities were not well coordinated. The report also found that the lack of access to the CCG SAR marine emergency radio system reduces the probability of an effective and coordinated SAR response in the event of a distress situation. In May 1999, the Ottawa and Hull 911 services, police departments, and fire departments, along with the Canadian Coast Guard Auxiliary and the CCG, reportedly held a joint meeting. It was suggested, inter alia, that all marine units be equipped with VHF radios to ensure effective communication. The 911 service in Hull also proposed the incorporation of a marine VHF station in their system, but no further action was taken. The Board is concerned with the effectiveness of current SAR and MCTS coverage within the NCR because MCTS stations do not monitor marine emergency channel 16 VHF radio communications in the NCR stretch of the Ottawa River, and the timely deployment of vessels cannot be coordinated according to the expectation of the CCG SAR plan. The Board encourages the CCG SAR organization to reassess the area plan. Amphibious Vehicles As a vessel (amphibious vehicle) under 5 in gross tonnage (GT) carrying fewer than 12passengers, the LadyDuckis not subject to compliance with the Hull Construction Regulations, the Hull Inspection Regulations, or the Standards for the Construction and Inspection of Small Passenger Vessels (TP11717). The Small Vessel Regulations define the life-saving appliances required on such small passenger-carrying vessels but do not address buoyancy or stability requirements. TCMS is revising the Construction Standards for Small Vessels (TP1332) that are applicable to pleasure craft up to 6m long and non-pleasure craft up to 15 in GT. The standards incorporate criteria for inherent buoyancy and stability for pleasure craft but not for non-pleasure craft. The Interim Small Passenger Vessel Compliance Program, re-introduced by TCMS in April 2001, addresses the inspection of conventional monohull-type vessels, with safety requirements in accordance with the Consolidated Regulations of the Canada Shipping Act and the above standards. Just before the publication of this report, TCMS indicated that owners of these vessels may not be legally required to comply with Transport Canada's Interim Small Passenger Vessel Compliance Program (ISPVCP). It should be noted, however, that the LadyDuck was subjected to the ISPVCP at the start of the 2002 season and was issued a Notice of Inspection and Compliance Monitoring for vessels not more that 15 in GT and carrying not more than 12 passengers under the Small Vessel Monitoring and Inspection Program. In May 1999, 13 of the 20 passengers on board an amphibious vehicle died when it sank in Lake Hamilton, Arkansas. The vehicle was a DUKW-type craft originally built for the transport of military personnel and supplies during World War II and subsequently converted for passenger excursion operation, in accordance with the then-current US Coast Guard (USCG) requirements. As a result of its investigation into the sinking, the National Transportation Safety Board (NTSB) identified several safety issues, including vehicle maintenance USCG inspection standards guidance to inspectors and owner-operators reserve buoyancy vehicle survivability The NTSB also made a number of safety recommendations to the USCG. Recommendation M-02-01 called for the provision of sufficient reserve buoyancy through passive means, such as built-in flotation, to ensure that the amphibious vehicles remain afloat and upright in the event of flooding. Recommendation M-02-03 required that, until such time as sufficient reserve buoyancy is provided, operators are to ensure that canopies (awnings) do not restrict horizontal or vertical escape by passengers in the event of sinking and that passengers don lifejackets before the vehicle becomes waterborne. USCG Guidelines for the Certification of DUKW Amphibious Vehicles (NVIC 1-01) was also issued to disseminate information on good marine practice in the inspection, operation, and repair of these amphibious vehicles to USCG marine inspectors, vehicle owners, operators, and repair facilities. The Board (TSB) is concerned that the safety of Canadian waterborne passengers is also at risk because current regulatory requirements (Canada Shipping Act and regulations), standards, and guidelines for ship inspectors and owners are complex and not fully compatible with each other and do not specifically address the unique operating characteristics of amphibious vehicles.